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Skin-Picking (Excoriation) Disorder (SPD)
The criteria for SPD closely parallel those of HPD and are new to DSM-5 [1]. An individual with SPD experiences excessive, repeated skin picking that they are unable to control, reduce, or cease on their own. Importantly, the behavior causes considerable distress, physical health consequences (e.g., tissue damage, infection), or impairments in relationships, work, school, or other domains of functioning.
Clients often present for treatment due to physical ramifications of picking, medical advice, or parental intervention.
Prevalence and Course SPD (i.e., excoriation, disorder) is estimated to impact 1–2% of the population, with community estimates suggesting a higher prevalence around 5% [12, 48]. As with HPD, rates are much higher among women than men.
However, again the extent to which this represents a true biological versus cultural difference in prevalence remains unknown. Although SPD can onset at any age, symptoms often present earlier than other OCRDs in childhood or adolescence [49].
It is also common for skin picking to follow the onset of a dermatological condition, such as acne or a rash, and then to persist [50]. As with HPD, over time these behav- iors become chronic and more severe, leading to impairment, and it is uncommon for symptoms to remit without treatment. Moreover, individuals may also experi- ence significant health consequences (e.g., scarring, damaged tissue, infection) and necessitate medical intervention as a result of excoriation [51].
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model is derived from Beck’s [54] cognitive theory of psychopathology, which pro- poses that our appraisals and responses to internal experiences (i.e., cognitions, physiological sensations) cause the onset and maintenance of anxiety disorders.
Specifically, clients with anxiety overestimate the likelihood as well as the severity of perceived threat (e.g., the likelihood of one’s heart racing being a sign of a heart attack or the severity of a presentation at work going poorly) [55]. In this way, mis- appraisals or distorted patterns of thinking about specific situations and stimuli bring about excessive emotional responding (e.g., anxiety, worry, depression) as well as maladaptive avoidant or safety behaviors (e.g., taking one’s pulse, over- preparing for the presentation) that are aimed to alleviate these distressing emotions or prevent a catastrophic, feared outcome (e.g., dying from a heart attack or losing one’s job). While these behaviors may be effective in downregulating affective responding in the moment, they contribute to the exacerbation of symptoms over time by reinforcing inaccurate or unhelpful beliefs about perceived threat and pre- venting opportunities to naturalistically extinguish fear or correct such beliefs. This model manifests transdiagnostically across anxiety disorders; however, contextual and discrete triggers as well as the content of cognitions are diagnostic-specific, as will now be discussed for each OCRD. Moreover, key distinctions (e.g., for hoard- ing, SPD, HPD) will be outlined.
OCD
As with anxiety disorders, in the cognitive-behavioral model of OCD, core dysfunc- tional beliefs contribute to the development and maintenance of OCD symptoms [56, 57]. According to this model and empirical research [e.g., 13], unwanted, intru- sive cognitions (e.g., thoughts, images, or urges involving contamination, symme- try, taboo topics, or harm) are highly prevalent phenomena (e.g., intrusive images of hitting someone with your car while driving). However, for individuals with OCD, these intrusions are misappraised as highly meaningful and significant (e.g.,
“Thinking about hitting someone with my car means that I am a dangerous person and likely to run someone over”) rather than being dismissed as mental noise. When this occurs, the thought is likely to progress to a clinical obsession, as the misap- praisal leads to significant fear, anxiety, and self-doubt. Furthermore, this motivates mental and behavioral actions to attempt to eliminate (e.g., thought suppression), reduce (e.g., checking the roads repeatedly to assure a pedestrian was not hit), or prevent (e.g., not driving at all) intrusions and resulting distress [e.g., 57]. As is observed for safety behaviors in anxiety disorders, compulsions are maintained via negative reinforcement (i.e., removing something aversive, in this case alleviating distress, such that the individual keeps performing these behaviors in the future).
Compulsions also reinforce inaccurate overestimates of threat and beliefs about the meaning of and one’s ability to tolerate internal experiences.
This model can also be illustrated by a man with persistent, distressing intrusive thoughts about contracting HIV/AIDS while using a public restroom. In response to
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the anxiety from these thoughts, he engages in extensive decontamination rituals (e.g., handwashing, showering) and seeks repeated reassurance from his partner and medical professionals to assure that he does not have HIV/AIDS. After engaging in these compulsions, he experiences immediate relief, reinforcing the behavior and increasing the likelihood that he will use them to regulate contamination fears in the future. However, he fails to learn that the negative outcome (e.g., developing HIV/
AIDS) would likely not have occurred without his compulsions. Moreover, he is unable to learn that he can tolerate the distress of using public restrooms and his thoughts about contracting a serious medical condition. Thus, these compulsions continue to increase and begin to take a considerable interpersonal toll, leading to work impairment and relationship distress.
BDD
The cognitive-behavioral model of BDD involves similar functional relationships and mechanisms as those outlined for anxiety disorders and OCD [58, 59]. However, in BDD the dysfunctional beliefs and misappraisals involve a specific focus on per- ceived physical flaws and the significance of one’s physical appearance. In this way, the functional relationships between BDD symptoms parallel that of anxiety disor- ders and OCD (e.g., the use of safety behaviors and avoidance to mitigate distress), while distinct symptoms also present that may warrant specific interventions (e.g., cognitions or behaviors more closely aligned with eating disorders, such as the ove- revaluation of one’s physical appearance). The triggers of symptoms tend to involve external perceptions of one’s image (e.g., looking in a mirror, seeing a photograph) in which such physical flaws are overly attended to or exaggerated (e.g., the sym- metry of one’s facial features [60]), leading to a poor self-concept and distorted self- image. Attention is increasingly biased toward appearance concerns, which leads to a distorted cognitive schema of how the individual appears to others.
For example, an individual may experience preoccupation with the appearance of her nose (e.g., “My nose is enormous and hideous”). As a result, she compares her nose to that of celebrities, which further elicits feelings of disgust, hopelessness, and frustration with her physical appearance. This preoccupation contributes to over- evaluation of appearance in her personal identity and leads her to anticipate rejection and judgment in social situations (e.g., “other people will feel disgusted and won’t want to look at me”). In response to these unpleasant and distressing emotions, she engages in repeated behaviors to distract from her nose (e.g., long makeup routines to make her eyes more noticeable), to alleviate her distress about how noticeable her nose is to others (e.g., seeking reassurance from her partner and friends). She also avoids social situations in which she might encounter new people due to fear of embarrassment and rejection. As with OCD and anxiety, these behaviors effectively reduce her distress in the moment, but in the long-term, they serve to maintain the attentional bias toward her perceived defective nose, her feelings of inadequacy, and distorted thoughts around her image and the significance of her appearance.
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Hoarding, Hair-Pulling Disorder, and Skin-Picking Disorder
Although there are some overlaps and similarities, hoarding, hair-pulling disor- der, and skin-picking disorder are best explained through conceptual models dis- tinct from those described for anxiety disorders, OCD, and BDD [43, 61]. First, the predominant cognitive and behavioral symptoms of these conditions (e.g., acquiring and maintaining possessions, hair pulling, skin picking) are often not experienced as intrusive or unwanted. Rather, they occur for a diverse number of affective or cognitive motivations (e.g., gratification, boredom, anger, not-just- right feelings) [34, 62]. For this reason, symptoms may be experienced as positive and reinforcing, neutral and automatic, or distressing and intrusive. There is thus a large degree of heterogeneity in the functional relationships between symptoms in hoarding disorder, HPD, or SPD, which aligns with empirical findings that these conditions may, in some cases, be better conceptualized with addictive, tic, or impulse spectrum disorders [10, 44, 63, 64]. As such, person-specific, func- tional assessment of symptoms is critical in clinical settings. Of note, distress in these conditions often presents due to attempts to stop or reduce the behavior (e.g., to dispose of items, pick skin less frequently) or from related impairment (e.g., resulting medical conditions, interpersonal conflicts), rather than a func- tional antecedent of the behavior.
First, in the cognitive-behavioral model of hoarding disorder [65], it is proposed that maladaptive beliefs about one’s possessions (e.g., about their potential value in the future) as well as about discarding them (e.g., “What if I make a mistake and need this item later or am responsible for wasting it?”) underlie hoarding symptoms.
However, unlike OCD and BDD, such beliefs contribute not only to negative emo- tions such as sadness/grief, anxiety/fear, and guilt/shame but also positive emotions about acquiring and maintaining possessions (e.g., pleasure, pride). Thus, acquiring and difficulty discarding are maintained not only by negative reinforcement (e.g., avoiding unpleasant emotions by choosing to save an item) but also positive rein- forcement (i.e., adding something rewarding that leads to an increase in the behav- ior; e.g., pleasure and excitement about retaining one’s possessions). In addition, individuals with hoarding disorder present with information processing deficits (e.g., in memory, decision-making, etc.) [66, 67] that are uniquely considered in the conceptual model of hoarding.
Similarly, a broader range of functional motivations for hair pulling and skin picking have been implicated [68, 69]. Again beliefs about hair pulling and skin picking can contribute to the development and maintenance of symptoms includ- ing beliefs about one’s inability to tolerate or control urges to pick/pull (e.g., “I can’t stand having this gray and wiry hair on my head”), about the benefits of pulling/picking (e.g., “I need to pick my skin in order to be able to concentrate”), permission giving thoughts (e.g., “I’ll just pull for 5 minutes and then stop”), and all/nothing beliefs (e.g., “I already messed up and started picking so I might as well keep going”). In addition, like compulsive rituals in OCD and BDD, indi- viduals may engage in hair pulling or skin picking as a maladaptive emotion regu-
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lation strategy aimed to reduce or alleviate generalized distress (e.g., feeling bored or anxious) or from thoughts and feelings of disgust, imperfection, or not- just-right experiences regarding one’s hair or skin (e.g., searching for a gray or coarse hair that does not belong). However, hair pulling and skin picking may also generate and be reinforced by positive affective experiences, and it is not uncom- mon for individuals to have mixed feelings about their pulling/picking behaviors.
For instance, while clients may be distressed by the loss of their hair or damage to their skin, they may also report gratification and pleasure when engaging in hair pulling and skin picking that maintain the behavior [64]. Finally, in some instances, hair pulling and skin picking may not be clearly linked to specific cognitive-affec- tive motivations and may present as a more automatic behavior (i.e., pulling/pick- ing without conscious awareness).
Therefore, due to the functional differences in the conceptual models of hoard- ing, HPD, and SPD, differential approaches for conceptualization and treatment are necessary (e.g., skills training for decision-making in hoarding) and will be dis- cussed in Treatment Implications below.